In Los Caprichos, Francisco de Goya's etchings depicting human follies, number 43 is entitled "El sueño de la razón produce monstruos." The story Dr. Andrews and his colleagues tell in this issue of the Journal 1 calls for Goya's vitriol. They describe a medical horror story, an epidemic of what they characterize as "self-mutilation and malingering" among Cubans detained at the U.S. naval base at Guantanamo Bay, Cuba, in late 1994 and early 1995.

The detainees were some 30,000 Cubans who fled their country for the United States on rafts and were intercepted by the U.S. Coast Guard. In a reversal of the long-standing U.S. policy allowing Cubans to bypass the asylum process, they were denied legal status as refugees and instead classified as migrants, with many fewer rights.2 Entry to the United States was restricted to those who were pregnant, were under 18 or over 70 years of age, or had medical conditions requiring treatment that could not be provided at Guantanamo Bay. As the authors describe it, when the severity of a condition (such as a burn) led to a "medical parole" (that is, a transfer to the United States for definitive care), "social contagion" resulted in a cluster of similar cases, a cluster that grew until that route to a medical parole was blocked. The detention camp was visited by a virtual epidemic of self-inflicted injuries, exacerbations of preexisting diseases due to deliberate noncompliance with treatment, pseudoseizures, and symptoms without ascertainable physical causes — conditions sufficiently complex that a cardiologist and a neurologist had to be recruited to assess them. The medical staff was sorely tried.

The severity of the injuries raises the question of psychiatric disorders. But the consensus among the medical providers was that there were no serious psychiatric disorders. I have no reason not to accept their diagnostic judgment. But when behavior that would be considered insane under ordinary circumstances (injecting diesel fuel into the anterior thigh or the scrotum, producing severe skin burns with molten plastic, inserting an electric cord into the urethra, and severing the Achilles' tendon) is motivated by "a single-minded interest in an obvious goal," the social context for that behavior must itself be insane. And indeed it was. The 30,000 refugees had put their lives at risk to flee Cuba at a time when it was official U.S. policy to grant them expedited asylum. That policy was suddenly reversed during the exodus, when many were at sea. They found themselves back in Cuba, imprisoned indefinitely, within sight of home and family but unable to reach either. Labeling their behavior "malingering" should not obscure the fact that these patients were suffering from severe disorders, whether or not they were self-inflicted.

The authors note that the "care and trust that ideally characterize [the physician–patient] relationship were supplanted by suspicion and deceit, as the patient attempted to `fool the doctor' into granting medical parole." The prisoners had become patients (that is, "made themselves sick") precisely because they were prisoners. Naturally, they viewed their doctors as guards manning the portals of their prison and sought freedom by any means they could muster, including deceiving the guards. But had not the doctors themselves raised questions about care and trust, insofar as they were gatekeepers for the detention center rather than doctors caring for patients whose illnesses were no less real because they were self-inflicted? The doctors were expected to detect manufactured disease and became expert at it. They were embedded in a system of military command that made it virtually impossible for them to attack the underlying disease: indefinite detention.

The pathogenesis of the epidemic was clear to the medical staff. "The prospect of an open-ended detention at Guantanamo Bay led to such extreme frustration that several hundred Cubans escaped the camps by scaling a 7-ft (2-m) fence topped with razor wire, swimming a mile (1.6 km) of open ocean, and finally traversing a minefield" — not to reach the United States, mind you, but "to return to Cuba." Two of those who attempted to escape drowned; another was killed when he stepped on a land mine.3

To prevent a repetition of this tragedy, Dr. Andrews and his colleagues propose two alternatives for future U.S. policy, should a similar situation arise: providing comprehensive on-site medical care so that evacuation is unnecessary, or uncoupling medical transfers from immigration so that the detainees are returned to the camps once their medical care is complete. Either of these policies might well have prevented the particular outbreak of conditions seen at Guantanamo Bay. However, neither policy would have prevented an analogous tragedy that arose from the same fundamental cause: the riot among the several thousand Cubans held during the same period at a separate detention camp in Panama, a riot that resulted in injuries to more than 220 U.S. soldiers and the hospitalization of 19 Cubans.2

The drama at Guantanamo Bay did not end until President Bill Clinton allowed the detained Cubans to enter the United States after a diplomatic détente had been reached with Cuban president Fidel Castro. The number of outpatient visits fell by more than half, and self-mutilation ceased. There were no more riots. The cause of the disease had been removed.

Accepting medical assignments constrained by larger political decisions without examining the moral grounds for those decisions and without scrutinizing the role assigned to doctors can compromise the medical mission. Chasing symptoms is an ineffective mode of management when their cause is clear. Andrews et al. note the "deteriorating economic conditions in Cuba" caused by the loss of economic subsidies from the former Soviet Union, along with stricter economic sanctions by the United States. The U.S. sanctions are having visible effects. Mass flight (when Castro allows it) is one measure of the sanctions' "effectiveness." But we changed our minds about welcoming refugees and transmuted them into migrants. Another measure of the "effectiveness" of the U.S. sanctions was the epidemic of 50,000 cases of optic and peripheral neuropathy in Cuba between 1991 and 1993. The team that studied the epidemic, assembled by the Pan American Health Organization with the cooperation of the Centers for Disease Control and Prevention, concluded that the outbreak was "linked to reduced nutrient intake caused by the country's deteriorating economic situation and the high prevalence of tobacco use."4 The incidence of the disease dropped sharply after the Ministry of Public Health inaugurated a program of multiple-vitamin supplementation for the Cuban population.

Thus, three unusual outbreaks of medical conditions — neuropathy, self-inflicted disease, and injuries caused by rioting — stemmed from U.S. economic sanctions. The sanctions may be aimed at Fidel Castro, but the victims are the ordinary citizens of Cuba. Castro looks as well fed as ever. Economic sanctions afflict civilians, not soldiers and not the leaders of autocratic societies. Yet the United States continues to employ such sanctions against dictators (or at least those dictators it suits present policy to condemn). When the sanctions are applied, they are all-encompassing. The interdicted trade with Cuba includes visits by medical delegations and the mailing of medical journals such as this one. Whom do medical journals empower, dictators or doctors? Can freedom be defended by suppressing information any more than by interrupting food supplies or drugs?

Iraq is an even more disastrous example of war against the public health. Two months after the end of the six-week war, which began on January 16, 1991, a study team from the Harvard School of Public Health visited Iraq to examine the medical consequences of sanctions imposed after the armed conflict. The destruction of the country's power plants had brought its entire system of water purification and distribution to a halt, leading to epidemics of cholera, typhoid fever, and gastroenteritis, particularly among children. Mortality rates doubled or tripled among children admitted to hospitals in Baghdad and Basra. Cases of marasmus appeared for the first time in decades. The team observed "suffering of tragic proportions. . . . [with children] dying of preventable diseases and starvation."5 Although the allied bombing had caused few civilian casualties, the destruction of the infrastructure resulted in devastating long-term effects on health.

An international group supported by the United Nations Children's Fund (UNICEF) carried out a more comprehensive study five months later by interviewing members of households selected to represent the Iraqi population.6 The age-adjusted relative mortality rate among children in the eight months after the war, as compared with the five years before the war, was 3.2. There were approximately 47,000 excess deaths among children under five years of age during the first eight months of 1991. The deaths resulted from infectious diseases, the decreased quality and availability of food and water, and an enfeebled medical care system hampered by the lack of drugs and supplies.

The Cuban and Iraqi instances make it abundantly clear that economic sanctions are, at their core, a war against public health. Our professional ethic demands the defense of public health. Thus, as physicians, we have a moral imperative to call for the end of sanctions. Having found the cause, we must act to remove it. Continuing to allow our reason to sleep will produce more monsters.

In mid-19th-century London, John Snow thought he discerned a pattern in the distribution of cases of cholera.7 He observed that in 10 days there were more than 500 fatal attacks of cholera within 250 yards of the spot where Cambridge Street joined Broad Street. What made that junction important was the fact that residents of the area obtained their water from the Broad Street pump. Because so many cases were aggregated in an area supplied by one water company, Snow petitioned the Board of Guardians of St. James parish to remove the handle of the pump. They did. The epidemic subsided.

Like John Snow, we have a responsibility to petition the authorities to remove the known causes of epidemics — in this case, by ending U.S. restrictions on trade in nonmilitary supplies. Doing so will not make us popular in some circles. But neither the Hippocratic oath nor its contemporary versions contain clauses that make self-interest grounds for exempting physicians from "acting for the benefit of the sick . . . and keeping them from harm and injustice."8